Cardiac Concussion (Commotio Cordis)

PEDIATRIC EM • PÉDIATRIE D’URGENCE

Cardiac concussion (commotio cordis)

Rahim Valani, MD;* Angelo Mikrogianakis, MD;† Ran D. Goldman, MD†

SEE ALSO COMMENTARY, PAGE 431.

ABSTRACT Blunt chest trauma in pediatric patients can result in various injuries to the myocardium. Cardiac concussion (commotio cordis) is seen in patients in whom the precordium has been struck with relatively little force at a vulnerable period of the cardiac cycle. These patients have no predisposing cardiac problems, and autopsy reveals no evidence of heart damage. The usual clinical presentation is that of immediate collapse secondary to a lethal arrhythmia. Prevention is the cornerstone of potentially decreasing the incidence with the aid of safety equipment and, possibly, immediate defibrillation. Key words: commotio cordis; chest trauma, pediatric; defibrillation; resuscitation

RÉSUMÉ Un traumatisme contondant au thorax chez les patients pédiatriques peut causer diverses lésions au myocarde. On constate une commotion cardiaque (commotio cordis) chez les patients dont la région précordiale a subi un choc relativement faible à un moment vulnérable du cycle cardiaque. Ces patients n’ont aucun problème cardiaque prédisposant et l’autopsie ne révèle aucun signe de dommages cardiaques. Sur le plan clinique, le phénomène se manifeste habituellement par un ef- fondrement immédiat secondaire à une arythmie mortelle. La prévention constitue la pierre an- gulaire de la réduction possible de l’incidence au moyen de matériel de sécurité, et peut-être, d’une défibrillation immédiate.

Introduction heart damage, even at autopsy.3,4 Emergency physicians, particularly those interested in injury prevention, should be Although trauma, in general, is the leading cause of mor- familiar with cardiac concussion because its mortality rate tality in children worldwide1,2 clinically significant isolated is as high as 85% and because it is often preventable.5 blunt chest trauma in children is rare. Chest injuries range from benign chest wall contusions to life-threatening con- Epidemiology ditions such as cardiac rupture, coronary artery laceration, Minneapolis’ Commotio Cordis registry, established in valvular disruption, cardiac contusion and cardiac concus- 1998, has documented only 128 cases in the United States, sion (commotio cordis). Of these, the most distressing may but because of rarity and underreporting, the true incidence be cardiac concussion because it occurs with relatively lit- is unknown.5–9 Most reported cases were the result of being tle force, its victims have normal underlying cardiac struck in the chest with a baseball,7,8,10 but cardiac concus- anatomy, and because there is no appreciable structural sion has occurred in ice hockey, lacrosse, softball, soccer,

*Fellow, and †Staff Physician, Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ont.

Received: June 14, 2004; final submission: Aug. 15, 2004; accepted: Sept. 3, 2004

This article has been peer reviewed.

Can J Emerg Med 2004;6(6):428-30

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karate and football,7,11–14 and may even occur after non-acci- fibrillation management consists of immediate basic life dental trauma.15–19 Nearly two-thirds of cases involve chil- support and prompt defibrillation.7,8,20,21,30 In 2001, auto- dren <16 years of age.12,20,21 The oldest patient we identified mated external defibrillators (AEDs) specifically modified was 20 years old, and the youngest was a 7-week infant to provide appropriate voltages (approximately one-third) whose father, frustrated with the infant’s crying, fatally to children ≤8 years of age or <55 lb (25 kg) became avail- struck his child on the chest.15 able (www.fda.gov/cdrh/mda/docs/k003819.pdf). The pad- dles are positioned differently (i.e., anterior/posterior Clinical presentation placement) for these patients. However, the best way to The majority of patients with commotio cordis lose con- implement public access defibrillation programs in antici- sciousness and collapse immediately, after a precordial in- pation of rare events such as cardiac concussion remains jury.8,12,20 Occasional reports describe a lucid interval in controversial.32,33 which the child is struck in the chest, falls to the ground, and then stands up briefly only to promptly collapse Summary again.12,20 If a monitor or defibrillator is immediately available, it will most likely reveal ventricular fibrillation.12,20 Cardiac concussion is an uncommon but devastating result Cardiac concussion is not a delayed phenomenon. of seemingly insignificant chest trauma. Most documented cases have occurred in children and adolescents during Pathophysiology sporting events such as baseball and ice hockey. The termi- Cardiac concussion occurs only when specific conditions nal event is usually ventricular fibrillation that results in are met. These involve force, exact timing and location of death if not promptly treated with defibrillation. Emer- impact, and a compliant chest wall. Impact force must be gency physicians can play a major role in awareness and sufficient to induce a ventricular dysrhythmia, but not so prevention campaigns and in evolving public access defib- great as to result in structural myocardial damage.22 In ex- rillation programs. perimental animal studies and retrospective case reviews, the ideal circumstances arise when a baseball strikes the Competing interests: None declared. chest wall at about 65 k/h, approximately the pitch speed achieved by 11- and 12-year-old boys who play ball at the References competitive level.8,23 Force transmission is directly related 1. Committee on Trauma Research (US). Injury in America: a con- to the hardness of the object, and in experimental studies tinuing public health problem. Committee on Trauma Research, the use of softer baseballs decreases the rate of ventricular Commission on Life Sciences, National Research Council and fibrillation induction from 69% to 11%.8 Ventricular fibril- the Institute of Medicine, Washington, DC: National Academy Press; 1985. lation is most common when the injury occurs directly to the chest wall overlying the heart.21,24 Attempts to refine 2. World Health Statistical Annual, 1994. Geneva, Switzerland: this localization have not been convincing.22 WHO; 1994. In animal models, induced cardiac concussion has led to 3. McCrory P. Commotio cordis. Br J Sports Med 2002;36:236-7. a variety of electrocardiographic findings, including com- plete heart block, bundle branch blocks, ST-segment 4. Maron BJ, Link MS, Wang PJ, Estes NA 3rd. Clinical profile of changes and atrial fibrillation.20,25–27 Ventricular fibrillation commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities. J Cardiovasc Elec- is most likely when the impact occurs just prior to the peak trophysiol 1999;10(1):114-20. of the T-wave.20 A compliant chest wall, as seen in most children, increases the susceptibility to cardiac 5. Maron BJ, Gohman TE, Kyle SB, Estes NA 3rd, Link MS. Clin- 28,29 ical profile and spectrum of commotio cordis. JAMA concussion. 2002;287(9):1142-6. Prevention and treatment 6. Link MS, Wang PJ, Estes NA 3rd. Ventricular arrhythmias in the athlete. Curr Opin Cardiol 2001;16(1):30-9.

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15. Baker AM, Craig BR, Lonergan GJ. Homicidal commotio 29. Kroell CK, Allen S, Warner CY. Inter-relationship of velocity cordis: the final blow in a battered infant. Child Abuse Negl and chest compression in blunt thoracic impact to swines. Soci- 2003;27(1):125-30. ety of Automotive Engineers (SAE) tech paper no 861881. Pro- ceedings of the 30th Stapp Car Crash Conference, Warrendale, 16. Denton JS, Filkins JA, Stephenson D. Criminal consequences of Pa. SAE, 1986: 99. commotio cordis. Am J Cardiol 2002;90(10):1181-2. 30. Lateef F. Commotio cordis: an underappreciated cause of sud- 17. Maron BJ, Mitten MJ, Greene Burnett C. Criminal conse- den death in athletes. Sport Med 2000;30(4):301-8. quences of commotio cordis. Am J Cardiol 2002;89(2):210-3. 31. Viano DC, Bir CA, Cheney AK, Janda DH. Prevention of com- 18. Denton JS, Kalelkar MB. Homicidal commotion cordis in two motion cordis in baseball: an evaluation of chest protectors. J children. J Forensic Sci 2000;45(3):734-5. Trauma 2000;19(6):1023-8.

19. Boglioli LR, Taff ML, Harleman G. Child homicide caused by 32. Strasburger JF, Maron BJ. Images in clinical medicine. Commo- commotio cordis. Pediatr Cardiol 1998;19:436-8. tio cordis. N Engl J Med 2002;347(16):1248.

20. Link MS, Wang PJ, Pandian NG, Bharati S, Udelson JE, Lee 33. Link MS, Maron BJ, Stickney RE, Vanderbrink BA, Zhu W, MY, et al. An experimental model of sudden death due to low- Pandian NG, et al. Automated external defibrillator arrhythmia energy chest-wall impact (commotio cordis) N Engl J Med detection in a model of cardiac arrest due to commotio cordis. 1998;338(25):1805-11. J Cardiovasc Electrophysiol 2003;14(1):83-7.

21. Link MS, Maron BJ, VanderBrink BA, Takeuchi M, Pandian NG, Wang PJ, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimen- Correspondence to: Dr. Ran D. Goldman, Division of Emergency Ser- tal model of commotio cordis. J Am Coll Cardiol 2001; vices, Hospital for Sick Children, 555 University Ave., Toronto ON M5G 37(2):649-54. 1X8; 416 813-4915, fax 416 813-5043, [email protected]

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